Elderly Patients' Knowledge of Drug Benefit Caps and Communication with Providers About Exceeding Caps

OBJECTIVES: Many elderly persons have drug benefits with coverage gaps, such as in Medicare Part D. Because beneficiaries who have such gaps must pay all drug costs, an accurate knowledge of gap thresholds and communication with providers about exceeding caps is important for elderly persons to manage out-of-pocket drug costs.
DESIGN: Cross-sectional survey.
SETTING: Health plan.
PARTICIPANTS: One thousand three hundred eight health plan members aged 65 and older. The study was a 2002 cross-sectional survey of elderly persons with capped drug benefits in a managed care plan in one state. Participants were sampled so that half reached coverage caps and half did not.
METHODS: Participants reported cap levels, communication with providers about exceeding caps, and decreased medication use due to cost.
RESULTS: Of the 1,308 participants (65.4% response rate), 68.6% did not know their correct cap level. Rates were similar in those who exceeded caps (66.2%), reported difficulty paying for medications (63.9%), or decreased medication use (66%). For participants who exceeded caps, 59.1% did not know beforehand that they were close to exceeding caps and 50.2% did not tell providers afterward. In multivariate analyses accounting for demographics and health, the oldest participants (≥85 vs 65–74) were at greater risk for not knowing cap levels (odds ratio (OR)=2.0, 95% confidence interval (CI)=1.2–3.4) and not telling providers about exceeding caps (OR=2.2, 95% CI=1.1–4.5).
CONCLUSIONS: Elderly patients often did not know correct cap levels and did not tell providers about exceeding caps. Providers, plans, and policymakers should actively assess and improve Medicare beneficiaries' knowledge of Part D coverage gaps.     

Primary care quality in the Medicare Program: comparing the performance of Medicare health maintenance organizations and traditional fee-for-service medicare

BACKGROUND: Since 1972, Medicare beneficiaries have had the option of enrolling in a Medicare-qualified health maintenance organization (HMO). Little information exists to inform beneficiaries' choices between the traditional fee-for-service (FFS) Medicare program and an HMO. OBJECTIVES: To compare the primary care received by seniors in Medicare HMOs with that of seniors in the traditional FFS Medicare program, and among HMOs, and to examine performance differences associated with HMO model-type and profit status. METHODS: Data were derived from a cross-sectional observational survey of Medicare beneficiaries 65 years or older in the 13 states with mature, substantial Medicare HMO markets. Only beneficiaries continuously enrolled for 12 months or more in traditional FFS Medicare or a qualified Medicare HMO were eligible. Data were obtained using a 5-stage protocol involving mail and telephone (64% response rate). Analyses included respondents who identified a primary physician and had all required data elements (N = 8828). We compared FFS and HMO performance on 11 summary scales measuring 7 defining characteristics of primary care: (1) access, (2) continuity, (3) integration, (4) comprehensiveness, (5) "whole-person" orientation, (6) clinical interaction, and (7) sustained clinician-patient partnership. RESULTS: For 9 of 11 indicators, performance favored traditional FFS Medicare over HMOs (P<.001). Financial access favored HMOs (P<.001). Preventive counseling did not differ by system. Network-model HMOs performed more favorably than staff/group-model HMOs on 9 of 11 indicators (P<.001). Few differences were associated with HMO profit status. CONCLUSIONS: The findings are consistent with previous comparisons of indemnity insurance and network-model and staff/group-model HMOs in elderly and nonelderly populations. The stability of results across time, geography, and populations suggests that the relative strengths and weaknesses of each system are enduring attributes of their care. Medicare enrollees seem to face the perennial cost-quality trade-off: that is, deciding whether the advantages of primary care under traditional FFS Medicare are worth the higher out-of-pocket costs.     

Eliminating out-of-pocket drug costs may improve outcomes after myocardial infarction--but at what cost to Medicare?

A standard four-drug regimen of aspirin, a beta-blocker, a lipid-lowering agent, and an angiotensin-converting-enzyme inhibitor or angiotensin-receptor blocker improves outcomes in survivors of myocardial infarction (MI), but adherence to this regimen is often poor. Choudhry et al. used a computer model to simulate the effectiveness and cost of improving medication adherence by eliminating out-of-pocket costs for the four-drug regimen in a hypothetical cohort of 65-year-old Medicare beneficiaries with MI. Based on the model's main assumptions, eliminating cost sharing for the regimen would be cost saving from a societal perspective, but would cost Medicare $7,182 per quality-adjusted life year. The results of the Choudhry et al. analysis suggest that improving adherence to a secondary prevention strategy by eliminating out-of-pocket costs for standard post-MI medications would be a cost-effective Medicare policy.     

Impact of medicare part D on access to and cost sharing for specialty biologic medications for beneficiaries with rheumatoid arthritis

Objective

Many worry that the use of specialty tiering for biologic disease‐modifying antirheumatic drugs (DMARDs) by Medicare Part D plans imposes a heavy financial burden on beneficiaries with rheumatoid arthritis (RA). To date, no one has examined the cost‐sharing structures for biologic DMARDs in Part D plans or the resulting cost burden for patients.

Methods

We followed 14,929 vulnerable, low‐income patients with RA who were enrolled in the Medicare Replacement Drug Demonstration (MRDD) in 2005. As the MRDD population transitioned into Part D in 2006, we examined correlates of Part D enrollment and compared the cost‐sharing provisions for biologic DMARDs in the Medicare Advantage and stand‐alone plans. We simulated the out‐of‐pocket costs of beneficiaries under 3 cost‐sharing scenarios.

Results

Eighty‐one percent of MRDD beneficiaries with RA enrolled in Part D. Enrollment predictors were female sex (odds ratio [OR] 1.48, 95% confidence interval [95% CI] 1.32–1.67), prior MRDD benefit use (OR 2.29, 95% CI 2.04–2.58), other self‐reported drug coverage (OR 1.53, 95% CI 1.36–1.71), and receiving an MRDD subsidy (OR 2.00, 95% CI 1.74–2.30). Compared with stand‐alone plans, Medicare Advantage plans had lower deductibles, lower premiums, and fewer prior authorization, step therapy, and quantity limit restrictions. However, ～75% of all plans used coinsurance as the preferred form of cost sharing. Out‐of‐pocket costs exceeded $4,000 annually in all cost‐sharing scenarios.

Conclusion

Most MRDD beneficiaries with RA enrolled in Part D. Although plans assume some costs for biologic DMARDs, the majority of costs are shifted to beneficiaries and to Medicare. Such cost shifting may place these medications out of the beneficiary's financial reach and expose Medicare to high financial liability.     

Awareness and enrollment in the Social/HMO

Marketing the Social/Health Maintenance Organization (S/HMO) relative to HMOs and fee-for-service health insurance is a complex undertaking. Awareness of the plans is relatively high among joiners and nonjoiners, as is awareness of the relative price and benefits of these competing options. Local market competition and out-of-pocket costs appear to be major factors in selection. Study subjects include a probability sample of S/HMO members in 1986 and probability samples of elderly Medicare beneficiaries who had enrolled in HMOs or were fee-for-service recipients within the demonstration communities.     

Observation Status,Poverty, and High Financial Liability Among Medicare Beneficiaries

Background

Medicare beneficiaries hospitalized under observation status are subject to cost-sharing with no spending limit under Medicare Part B. Because low-income status is associated with increased hospital use, there is concern that such beneficiaries may be at increased risk for high use and out-of-pocket costs related to observation care. Our objective was to determine whether low-income Medicare beneficiaries are at risk for high use and high financial liability for observation care compared with higher-income beneficiaries.

Medicare Part D's effect on the under- and overuse of medications: a systematic review

OBJECTIVES: To evaluate the literature regarding the effect of Medicare Part D on the under‐ and overuse of specific medications and corresponding health outcomes. DESIGN: Systematic review. SETTING: Medline search of the peer‐reviewed literature from January 1, 2006, to October 8, 2010. PARTICIPANTS: Medicare beneficiaries who obtained drug insurance from the Part D program. MEASUREMENTS: The review evaluated changes in the use of specific drugs or drug classes after implementation of Part D, as described in original, peer‐reviewed articles. RESULTS: Nineteen articles met inclusion criteria. Part D's implementation was associated with greater use of essential medications such as clopidogrel and statins, especially in beneficiaries who had been previously uninsured, but increases in inappropriate antibiotic use for the treatment of acute respiratory tract infections and increases in claims for the often overused proton pump inhibitor drug class were also observed. In the Part D transition period, dually eligible beneficiaries' drug use remained largely unchanged. When beneficiary cost sharing increased in the coverage gap, use of essential and overused medications declined. CONCLUSION: Increasing drug coverage led to greater use of underused essential medications and inappropriate, or overused, medications under Medicare Part D. Despite efforts to have it do so, the Part D benefit did not sufficiently discriminate between essential and nonessential medication use.     

The "Hassle Factor": what motivates physicians to manipulate reimbursement rules?

BACKGROUND: Some physicians are willing to misrepresent clinical information to insurance companies to circumvent appeals processes. Whether characteristics of appeals processes affect the likelihood of misrepresentation is unknown. This study sought to determine the relationship between the likelihood of a successful appeal, appeals process length, and severity of the health condition and physicians' willingness to sanction deception. METHODS: A random sample of 1617 physicians was surveyed by mail to assess their willingness to accept an insurance company restriction, to appeal the restriction, or to misrepresent the facts to an insurance company to obtain coverage for a patient. RESULTS: Most respondents would appeal (77%) rather than accept (12%) or misrepresent (11%) regarding a restriction on medically necessary care. Physicians' decisions were related to the likelihood of a successful appeal (chi(2) = 7.56; P =.02), the appeals process length (chi(2) = 8.53; P =.01), and the severity of the medical condition (chi(2) = 71.10; P<.001). A small but significantly larger number of physicians chose to misrepresent the facts to an insurer as the appeals process became more cumbersome. Among physicians asked about severe angina, their decisions were particularly affected by the hassle associated with appealing, being more likely to choose to misrepresent the facts to the insurer than to appeal as the hassle increased. CONCLUSIONS: Physicians are more willing to sanction deception when the appeals process is longer, the likelihood of a successful appeal is lower, and the health condition is more severe. Changes in the difficulty of appeals processes may ease the tensions physicians face regarding patient advocacy and honesty.